56-character length restrictions, including spaces. IRG: ZHL1 SRC(99) Received: 01/15/2004 1. TITLE OF PROJECT A Curriculum for Clinical Research Training in Vermont 2. RESPONSE TO SPECIFIC REQUEST FOR APPLICATIONS OR PROGRAM ANNOUNCEMENT OR SOLICITATION [] NO [] YES (If "Yes," state number and title) Number: HL-04-004 Tit,e:Clinical Research Curriculum Award 3. PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR New Investigator [] No [] Yes 3a. NAME (Last, first, middle) Littenberg, Benjamin 3b. DEGREE(S)MD I 3c. POSITION TITLE 3d. MAILING ADDRESS (Street, city, state, zip code) Professor of Medicine 371 Pearl Street 3e. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT Division of General Internal Medicine Burlington, VT 05401 3f. MAJOR SUBDIVISION College of Medicine 3g. TELEPHONE AND FAX (Area code, number and extension) E-MAIL ADDRESS: TEL: 802-847-8268 ] FAX: 802-847-0319 Benjamin.Littenberg@UVM.edu J 4. HUMAN SUBJECTS 4a. Research Exempt[] No [] Yes 5. VERTEBRATE ANIMALS [] No [] Yes RESEARCH If "Yes,"Exemption No. [] No 4b. Human Subjects 4c. NIH-defined Phase III 5a. If"Yes," IACUC approval Date 5b. Animal welfare assurance no [] Yes AssuranceNo. Clinical Trial A3301-01 FWA 00000723 [] No [] Yes 6. DATES OF PROPOSED PERIOD OF 7. COSTS REQUESTED FOR INITIAL 8. COSTS REQUESTED FOR PROPOSED SUPPORT (month, day, year--MM/DD/YY) BUDGET PERIOD PERIOD OF SUPPORT 7a. Direct Costs ($) 7b. Total Costs ($) 8a. Direct Costs ($) 8b. Total Costs ($) From 06/01/05 J Through05/31/10 $278,180 $300,000 $1,390,843 $1,500,000 9. APPLICANT ORGANIZATION 10. TYPE OF ORGANIZATION Name University of Vermont and State Agricultural Public: ---> [] Federal [] State [] Local College Private: _ [] Private Nonprofit Address 340 Waterman For-profit: _-+ [] General [] Small Business 85 South Prospect Street [] Woman-owned _[] Socially and Economically Disadvantaged Burlington, Vermont 05405-0160 11, ENTITY IDENTIFICATION NUMBER 1030179440A1 DUNS NO. 06-681-1191 Institutional Profile File Number (if known) CongressionaIDistrict vm 12. ADMINISTRATIVE OFFICIAL TO BE NOTIFIED IF AWARD IS MADE 13. OFFICIAL SIGNING FOR APPLICANT ORGANIZATION Name Ruth Farrell Name William P!oog, Assistant Director Title Director Title Address Office of Sponsored Programs Address (_ff_& 00_ _l_P_or_l[l_"ns 340 Waterman 340 Waterman University of Vermont University of Vermont Burlington, VT 05401-0160 Burlington, VT 05401-0160 Telephone 802-656-3360 FAX 802-656-1326 Telephone 802-656-3360 FAX 802-656-1326 E-Mail ospuvm@zoo.uvm.edu E-Mail ospuvm@zoo.uvm.edu 14. PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR ASSURANCE: I certify that the SIGNATURE OF PI/PD NAMED IN 3a. DATE statements herein are true, complete and accurate to the best of my knowledge. I am (In inF. "Per" signature not acceptable.) / aware that any false, fictitious, or fraudulent statements or claims may subject me to [unreadable] j.f,_ , criminal, civil, or administrative penalties. I agree to accept responsibility for the scientific conduct of the project and to provide the required progress reports if a grant is awarded as a result of this a.Eplication. 15. APPLICANT ORGANIZATION CERTIFICATION AND ACCEPTANCE: Icertify that the DATE statements herein are true, complete and accurate to the best of my knowledge, and accept the obligation to comply with Public Health Services terms and conditions if a grant is awarded as a result of this application. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal,civil, or administrative penalties. PHS 398 (Rev. 05/01 Face Page Form Page 1